Clinical image Intestinal tuberculosis presenting as a bowel obstruction Mary-Margaret Brandt, M.D. a , Paul N. Bogner, M.D. b , Glen A. Franklin, M.D. a, * a Department of Surgery, Division of Trauma, Burn, and Emergency Surgery, Trauma Burn Center, Room 1C421-UH Box 0033, 1500 East Medical Center Dr., Ann Arbor, MI 48109-0033, USA b Department of Pathology, University of Michigan, Ann Arbor, MI, USA Manuscript received August 7, 2001; revised manuscript December 21, 2001 A 58-year-old man was admitted to the medical intensive care unit with respiratory failure and a 40-pound weight loss. He denied risk factors for tuberculosis (TB) including human immunodeficiency virus (HIV), foreign travel, pre- vious TB exposure, homelessness, migrant working, or in- travenous drug use. The patient was diagnosed with pulmo- nary tuberculosis and started on four-drug antibiotic therapy with isoniazid, pyrazinamide, rifampin, and streptomycin. Computed tomography (CT) revealed extensive pulmonary disease. After extubation, he was transferred out of the medical intensive care unit. On hospital day 21, he developed persistent nausea and vomiting after a 1-week history of obstipation. He had no previous abdominal operations. His abdomen was non- tender but distended. A CT scan showed a small bowel obstruction with a transition point. On exploration there were multiple small bowel strictures (Fig. 1). There were three obstructing strictures in the ileum and two strictures narrowing the jejunum. Multiple enlarged lymph nodes were present in the mesentery. The obstructing strictures were resected and a single primary anastomosis was per- formed. Pathologic examination demonstrated tuberculous enteritis with bowel wall and mesenteric lymph node in- volvement (Fig. 2). Acid-fast bacilli were seen on histologic evaluation of the bowel, a rare finding in tuberculosis en- teritis. The presence of acid-fast bacilli to this degree is indicative of extensive disease. The patient remained on the four-drug antibiotic regimen and required ventilator support postoperatively. Ultimately, he succumbed to disseminated tuberculosis on hospital day 49. The diagnosis of tuberculosis enteritis is difficult given the presentation is usually vague in nature. This disease is rarely seen because the incidence is low in the United States. Mycobacterium tuberculosis is the most common species observed. Tuberculous enteritis is the most common extrapulmonary manifestation of this disease occurring in approximately 2% of patients with pulmonary TB [1]. This patient presented with pulmonary disease and then mani- * Corresponding author. Tel.: 1-734-936-9666; fax: 1-734-936- 9657. E-mail address: gafrank@umich.edu. Fig. 1. Photograph of operative findings. There are multiple small bowel strictures with obstruction (white arrows) and enlarged mesenteric lymph nodes (black arrow). Fig. 2. Histological evaluation of the ileum. (b) Hematoxylin and eosin stain demonstrating extensive bowel wall inflammation and caseating gran- ulomas (black arrows). (B) Fite acid-fast stain of the same region as panel A showing multiple acid-fast bacilli (red staining). (C) Hematoxylin and eosin stain of the strictured segment of ileum. There is a loss of normal mucosa in transition to the fibrotic stricture (black arrow). The American Journal of Surgery 183 (2002) 290 –291 0002-9610/02/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved. PII: S0002-9610(02)00788-2